In Canada, we have been mulling the notion of a national program to cover the cost of prescription drugs for more than half a century.

The philosophical/moral arguments for pharmacare are powerful and compelling. The economic ones are almost as strong.

Medicare was introduced gradually in the 1950s and 1960s because of an untenable situation. Families were being bankrupted by hospital and physician bills, and patients were going without treatment - even for life-threatening conditions - for lack of money.

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The answer was a universal insurance program that was state-funded, a pooling of risk across the entire population that would ensure no one would go without essential care. A single-payer system could also contain costs.

Today, an eerily similar situation exists with prescription drugs. People with conditions such as cancer (particularly if they are treated outside hospital), multiple sclerosis and rheumatoid arthritis can face debilitating out-of-pocket expenses.

As happened prior to medicare, programs have sprung up piecemeal to deal with the most egregious situations.

Decades ago, physicians would take payments-in-kind from cash-strapped patients, and religious hospitals offered charitable care to the desperate. Then government programs were fashioned before making way to provincial insurance plans and, finally, a cohesive national system of medicare (more or less) with Ottawa kicking in money to ensure citizens of have-not provinces did not have second-rate access to care.

As prescription drugs became a key component of the medical toolbox, the same pattern repeated itself. Drugs were offered at no cost to "indigents," then to seniors (who prior to income supplements often lived in poverty) and then to those on various forms of social assistance.

Many provinces and territories responded to public pressure and created catastrophic drug plans to bail out folks whose drug costs gobble up an inordinate portion of family income.

There are eloquent proponents for pharmacare that would offer coverage with no deductibles or co-payments, like we have for hospitals and physician services. But it is widely accepted that people can be called upon to contribute to their drug costs and the state step in only when these costs become "catastrophic" - defined as 2 to 20 per cent of income depending on the province and income level. But millions of Canadians remain uninsured or underinsured for essential care in the form of prescription drugs.

There is a basic unfairness that exists in the wide provincial variations. The fact that a person with a $20,000 out-of-hospital drug cancer treatment will pay nothing out-of-pocket in Nunavut, $3,000 in British Columbia and $20,000 in Prince Edward Island offends the principles of medicare and Canadian values.

Everyone knows the situation is unjust and untenable. And everyone knows that the solution lies in Ottawa stepping in and levelling the playing field. That means introducing some national standards for coverage and putting some cash on the table so the provinces conform.

Moreover, every major national party - Conservatives, Liberals, New Democrats - has at some point promised to resolve this problem.

So why the hesitation? Why the inaction?

Fear.

There is real fear that by doing what is acknowledged as the right thing, Ottawa will open a can of fiscal whoopass and saddle itself with a burdensome expense that grows like a tumour.

It's not an unreasonable fear.

Look at the situation in Quebec. It was the last province to adopt medicare (in 1970), but the first to create a universal drug insurance program (1996).

It is mandatory in the province to have prescription drug insurance - purchased either from private companies or from the provincial health insurance program.

In its first year, the provincial drug program collected $169-million in premiums and required $700-million in state funding. A little more than decade later, premiums are forecast to have risen to $732-million and the state contribution to $2.5-billion.

Now, soaring premiums are undermining the notion of affordable public drug insurance. Data also suggest that there is a shift (or dumping) of expensive patients from private plans to the public plan.Those trends - never mind the dollar figures - strike fear in the hearts of politicians.

What is not considered near often enough in the endless debate about pharmacare (and its less frightening cousin catastrophic drug insurance) is that the equation is not one-sided.

Yes, a drug insurance program is costly. But it is only unaffordable if we continue to spend the way we do now. Quebec has shown the folly of doing so.

The key to a viable drug insurance program is cost control and firm regulation. That's why these programs work in Europe, Australia and New Zealand. In Canada we talk endlessly about how much drugs costs; we should be instead talking about how we can make essential drugs affordable for individuals and the collectivity.

Catastrophic drug insurance needs a solid foundation, a strategy. And Canada has had a National Pharmaceuticals Strategy since 2004 - at least on paper. It spells out the prerequisites for managing drug costs, including:

* Establishing a national formulary (or list of drugs to be covered), and that has begun with the Common Drug Review.

* Implementing drug pricing and purchasing strategies to obtain the best prices for drugs and vaccines. Some provinces have acted to cut generic prices, albeit in a ham-fisted manner. But why don't we have bulk purchasing?

* Strengthening the evaluation of real-world drug safety and effectiveness. Stated plainly, we pay for a lot of drugs that don't work.

* Using technology for e-prescribing to reduce waste and help avoid dangerous adverse reactions.

* Improving the prescribing behaviour of health professionals. No one likes to talk about it, but there is a lot of inappropriate prescribing going on: expensive drugs used when cheaper ones work fine, along with overprescribing and underprescribing of treatment for various conditions.

A drug plan doesn't have to pay for everything, but it needs to cover the essentials and do so fairly.

Instead of dragging their feet on this issue and prolonging the injustice for many Canadians, our political leaders and policy-makers need to put their noses to the grindstone and implement a series of measures that will make catastrophic drug insurance feasible, affordable and sustainable.